Healthcare Provider Details

I. General information

NPI: 1013264498
Provider Name (Legal Business Name): C. EMMA BURROUS, PH.D., PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2012
Last Update Date: 08/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 PINE ST
BURLINGTON VT
05401-8421
US

IV. Provider business mailing address

118 PINE ST
BURLINGTON VT
05401-8421
US

V. Phone/Fax

Practice location:
  • Phone: 802-657-4042
  • Fax: 802-862-4062
Mailing address:
  • Phone: 802-657-4042
  • Fax: 802-862-4062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number048-0000905
License Number StateVT

VIII. Authorized Official

Name: C. EMMA BURROUS
Title or Position: OWNER
Credential: PH.D.
Phone: 802-657-4042